2.1. Case presentation
A 64-year-old male on the heart transplant waiting list was admitted to
the Cardiovascular Surgery ward of our hospital for intracerebral
hemorrhage. He had undergone LVAD (HeartMate II, Thoratec Corporation,
Pleasanton, CA, USA) implantation at 59 years of age due to dilated
cardiomyopathy causing left ventricle failure. The subcortical
hemorrhage was treated conservatively and the patient was rehabilitated
in the same ward without any complications. However, the patient
developed fever, nausea, and right upper quadrant pain with shock
vitals. Computed tomography revealed an enlarged gallbladder with a
thickened wall and surrounding fatty tissue opacity. He was diagnosed
with acute cholecystitis and was referred to our department. Emergent
surgery was considered. However, conditions were not favorable due to
the infection and heart failure with an LVAD. Thus, PTGBD was performed
to reduce inflammation in the gallbladder. The cholecystitis resolved in
a few days. An elective LC was planned for 3 months after the PTGBD, to
avoid the risk of recurrent cholecystitis that could cause LVAD
infection.
The patient was taking 3.5 mg/d of warfarin with a prothrombin
time-international normalized ratio of 2.0–3.0 because of the LVAD. In
preparation for surgery, the anticoagulation was reversed with
prothrombin complex concentrate. After induction of general anesthesia,
markings were made on the skin along the subcutaneous driveline to avoid
injury during trocar insertion (Figure 1). The first endoscopic trocar
was inserted via the open method (15 mm vertical incision at the
umbilicus). The pneumoperitoneum pressure was set at 10 mmHg and a 30°
scope was inserted. The other trocars were placed as demonstrated in
Figure 1. No adhesions were found around the LVAD, which was placed in
the preperitoneal space. However, some adhesions were found around the
gallbladder (Figure 2a, b, Additional File 1: Video S1). The neck of the
gallbladder was thickened and a sub-total resection was performed. To
ensure that there was no postoperative bleeding, a drain was placed in
the liver bed and the operation was completed. The duration of surgery
was 114 min, and the estimated amount of blood loss was 5 mL.